心臟衰竭病人出院後照護連續性及就醫機構層級與照護結果及費用之相關性

Associations of continuity and level with outcomes and expenses of post-discharge care for patients with heart failure

邱翰憶(Han-Yi Chiu) ； 鄭守夏(Shou-Hsia Cheng) ； 董鈺琪(Yu-Chi Tung)

《台灣公共衛生雜誌》 35卷1期 (2016/02) Pp. 66-79

https://doi.org/10.6288/TJPH201635104065

摘要

目標：心臟衰竭住院治療1年內住院率、死亡率及醫療費用均很高。為改善出院後照護結果及控制費用，出院後之門診照護逐漸受重視。本研究目的係探討心臟衰竭病人出院後，門診照護連續性及層級與照護結果及費用之相關性。方法：本研究使用全民健康保險研究資料庫全國代表性樣本，總計2007年至2011年出院之2,909位心臟衰竭病患納入分析。本研究使用廣義估計方程式及群集存活分析控制病人、醫師及機構特性，以檢測出院後門診照護連續性及層級與出院後1年內照護結果及費用之相關性。結果：出院後照護連續性較高與1年內再住院次數較低有關，照護連續性高與1年內死亡率較低有關，而照護連續性較高與總費用(門診、急診及住院照護)較低有關。出院後門診照護於區域醫院、地區醫院及診所的總費用低於醫學中心。結論：出院後照護連續性較高，照護結果較佳且總費用較低；除此，出院後主要於社區醫院或診所接受門診照護之病患結果與醫學中心無差異，但總費用較低。

關鍵字

心臟衰竭 ； 照護連續性 ； 就醫機構層級 ； 照護結果 ； 醫療費用

並列摘要

Objectives: One-year readmission and mortality rates, and medical expenses after hospitalization for heart failure are very high. To improve outcomes and control costs of post-discharge care, outpatient care after discharge has been increasingly emphasized. The objective of this study was to examine the associations of continuity and level with outcomes and expenses of post-discharge outpatient care for heart failure patients. Methods: This study used data from a nationwide representative sample through the National Health Insurance Research Database. A total of 2909 heart failure patients discharged from hospitals between 2007 and 2011 were selected for analysis. Generalized estimating equation and clustered survival models were performed after adjustment for patient, physician, and institution characteristics to examine the associations of outpatient continuity and level with 1-year outcomes and expenses of post-discharge care. Results: Higher continuity of care after discharge was associated with fewer re-hospitalizations within 1 year after discharge. High continuity of care was associated with lower 1-year mortality rates. Higher continuity of care was associated with lower total expenses for ambulatory, emergency room, and inpatient care. Patients who received outpatient care in regional hospitals, district hospitals, and clinics had lower total expenses compared with patients in academic medical centers. Conclusions: Higher continuity of care after discharge is associated with better outcomes and lower total expenses. Moreover, patients who mainly receive post-discharge outpatient care in community hospitals or clinics have similar outcomes and lower total expenses compared with patients in academic medical centers.

並列關鍵字

heart failure ； continuity of care ； level of care ； outcomes of care ； medical expenses

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